The Diagnosis and Management of Alpha-1 Antitrypsin Deficiency in the Adult

Background: The diagnosis and clinical management of adults with alpha-1 antitrypsin deficiency (AATD) have been the subject of ongoing debate, ever since the publication of the first American Thoracic Society guideline statement in 1989.¹ In 2003, the "American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement: Standards for the Diagnosis and Management of Individuals with Alpha-1 Antitrypsin Deficiency" made a series of evidence-based recommendations, including a strong recommendation for broad-based diagnostic testing of all symptomatic adults with chronic obstructive pulmonary disease (COPD).² Even so, AATD remains widely under-recognized. To update the 2003 systematic review and clinical guidance, the Alpha-1 Foundation sponsored a committee of experts to examine all relevant, recent literature in order to provide concise recommendations for the diagnosis and management of individuals with AATD. Purpose: To provide recommendations for: (1) the performance and interpretation of diagnostic testing for AATD, and (2) the current management of adults with AATD and its associated medical conditions. Methods: A systematic review addressing the most pressing questions asked by clinicians (clinician-centric) was performed to identify citations related to AATD that were published since the 2003 comprehensive review, specifically evaluating publications between January 2002 and December 2014. Important, more recent publications were solicited from the writing committee members as well. The combined comprehensive literature reviews of the 2003 document and this current review comprise the evidence upon which the committee's conclusions and recommendations are based. Results: Recommendations for the diagnosis and management of AATD were formulated by the committee. Conclusions: The major recommendations continue to endorse and reinforce the importance of testing for AATD in all adults with symptomatic fixed airflow obstruction, whether clinically labeled as COPD or asthma. Individuals with unexplained bronchiectasis or liver disease also should be tested. Family testing of first-degree relatives is currently the most efficient detection technique. In general, individuals with AATD and emphysema, bronchiectasis, and/or liver disease should be managed according to usual guidelines for these clinical conditions. In countries where intravenous augmentation therapy with purified pooled human plasma-derived alpha-1 antitrypsin is available, recent evidence now provides strong support for its use in appropriate individuals with lung disease due to AATD.

Long term study into surgical re-exploration of the 'free flap in difficulty'

BACKGROUND

Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote.

MATERIAL AND METHODS

We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome.

RESULTS

Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases.

CONCLUSION

We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.

["Flowsecure" artificial urinary sphincter: a new adjustable artificial urinary sphincter concept with conditional occlusion for stress urinary incontinence]

INTRODUCTION

To spread de concept of a new artificial urinary sphincter with conditional occlusion for stress incontinence. The new prototype was conceived and designed in The Institute of Urology and Nephrology of London by Professor Craggs M. and Professor Mundy A.R.

METHODS

The FlowSecure sphincter consists of an adjustable pressure-regulating balloon, a stress relief reservoir, a control pump and valve assembly unit with self-sealing port and a urethral cuff. The pressure regulating balloon determinates de operating pressure of the device; the pressure is adjustable in the range 0-80 cm H2O and can be altered by injection or removal of normal saline through the self sealing port. The stress relief balloon transmits transient intrabdominal pressure to the cuff during periods of stress. An adjustable circular urethral cuff minimises creasing and possible stress fractures.

RESULTS

The device is implanted as a one-piece assembly which is pre-filled with sterile saline. The surgical technique is simple and associated with little handling, reducing risk of infection and potential assembly errors. The adjustable pressure regulating balloon in association with the stress relief reservoir enables the cuff occluding pressure to be set at a low range, therefore reducing the risk for atrophy and erosion.

DISCUSSION

The new FlowSecure urinary artificial sphincter with conditional occlusion is designed to provide good continence rates adjusting regulating pressures when needed and conceived to reduce the risk of potential complications associated with excessive occluding pressures and mechanical failures.

Assessing the influence of field- and GIS-based inquiry on student attitude and conceptual knowledge in an undergraduate ecology lab

Combining field experience with use of information technology has the potential to create a problem-based learning environment that engages learners in authentic scientific inquiry. This study, conducted over a 2-yr period, determined differences in attitudes and conceptual knowledge between students in a field lab and students with combined field and geographic information systems (GIS) experience. All students used radio-telemetry equipment to locate fox squirrels, while one group of students was provided an additional data set in a GIS to visualize and quantify squirrel locations. Pre/postsurveys and tests revealed that attitudes improved in year 1 for both groups of students, but differences were minimal between groups. Attitudes generally declined in year 2 due to a change in the authenticity of the field experience; however, attitudes for students that used GIS declined less than those with field experience only. Conceptual knowledge also increased for both groups in both years. The field-based nature of this lab likely had a greater influence on student attitude and conceptual knowledge than did the use of GIS. Although significant differences were limited, GIS did not negatively impact student attitude or conceptual knowledge but potentially provided other benefits to learners.

Three-dimensional MRI of the male urethrae with implanted artificial sphincters: initial results

The aim of this study was to develop a method for simultaneous 3D visualization of a new type of artificial urethral sphincter (AUS) and adjacent urinary structures. Serial MR tomograms were acquired from seven men after AUS implantation. 3D reconstruction was performed by thresholding original (positive) and inverted (negative) image intensity and by subsequently fusing positive and negative images. Results show that the bladder, cuff and balloons of the AUS of originally high intensity were imaged in 3D by thresholding the positive datasets. The urethrae and corpora cavernosa penis of originally low intensity were displayed in 3D by thresholding the negative datasets. Fusion of the positive and negative datasets allowed simultaneous visualization of the AUS complex and adjacent urinary structures. All the structures of interest were also clearly seen by interactive multiplanar reformatting. Coronal tomographic datasets provided better 3D and reformatted 2D images than sagittal and transverse datasets. This technique offers a simple means for evaluating the complex urethral anatomy and the AUS, and has potential for improved 3D visualization of many other complex morphological and pathological conditions.

A simple and fail safe method for digital tourniquet

Digital tourniquets are commonly used to provide a bloodless field for surgery to the finger. Such tourniquets, however, are potentially harmful and disastrous consequences occur if they are accidentally left in place. We propose a modification of the rubber glove tourniquet technique that will provide a safe and reliable tourniquet.

Neuromodulation through sacral nerve roots 2 to 4 with a Finetech-Brindley sacral posterior and anterior root stimulator

STUDY DESIGN

Investigation of five patients receiving an implant, using laboratory cystometry and self-catheterisation at home.

OBJECTIVES

To use the established Finetech-Brindley sacral root stimulator to increase bladder capacity by neuromodulation, eliminating the need for posterior rhizotomy, as well as achieving bladder emptying by neurostimulation.

SETTING

Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.

METHODS

Five patients underwent implantation of a Finetech-Brindley stimulator without rhizotomy of the posterior roots. This was either a two channel extradural device (four cases) or a three channel intrathecal device (one case). In each patient, the implant was configured as a Sacral Posterior and Anterior Root Stimulator (SPARS). Postoperatively, repeated provocations using rapid instillation of 60 ml saline were used to determine the relative thresholds for neuromodulation using each channel. The effect of continuous neuromodulation was examined in the laboratory using slow fill cystometrograms, and conditional stimulation was also studied (neuromodulation for 1 min to suppress hyperreflexic contractions as they occurred). In one patient, neuromodulation was applied continuously at home, and volumes at self catheterisation recorded in a diary.

RESULTS

Reflex erections were preserved in each patient. In three patients, detrusor hyperreflexia persisted postoperatively and neuromodulation via the implant was studied. In these three patients, the configuration was: S2 mixed roots bilaterally (channel B), and S34 bilaterally (channel A). Both channels could be used to suppress provoked hyperreflexic contractions, with the S2 channel effective at a shorter pulse width than S34 in a majority of cases. Continuous stimulation more than doubled bladder capacity in two out of three patients during slow fill cystometry. Conditional stimulation was highly effective. In the one patient who used continuous stimulation at home, bladder capacity was more than doubled and the effect was comparable with anticholinergic medication. Bladder pressures >70 cm water could be achieved with intense stimulation in three patients, but detrusor-external urethral sphincter dyssynergia (DSD) prevented complete emptying.

CONCLUSIONS

Neuromodulation via a SPARS was effective and may replace the need for posterior rhizotomy. However, persisting DSD may prevent complete bladder emptying and warrants further investigation.

The acute effects of continuous and conditional neuromodulation on the bladder in spinal cord injury

STUDY DESIGN

Laboratory investigation using serial slow-fill cystometrograms.

OBJECTIVES

To examine the acute effects of different modes of dorsal penile nerve stimulation on detrusor hyperreflexia, bladder capacity and bladder compliance in spinal cord injury (SCI).

SETTING

Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.

METHODS

Fourteen SCI patients were examined. Microtip transducer catheters enabled continuous measurement of anal sphincter, urethral sphincter and intravesical pressures. Control cystometrograms were followed by stimulation of the dorsal penile nerve at 15 Hz, 200 micros pulse width and amplitude equal to twice that which produced a pudendo-anal reflex. Stimulation was either continuous or in bursts of one minute triggered by a rise in detrusor pressure of 10 cm water (conditional). Further control cystometrograms were then performed to examine the residual effects of stimulation.

RESULTS

Bladder capacity increased significantly during three initial control fills. Continuous stimulation (n=6) significantly increased bladder capacity by a mean of 110% (+/-Standard Deviation 85%) or 173 ml (+/-146 ml), and bladder compliance by a mean of 53% (+/-31%). Conditional stimulation in a different group of patients (n=6) significantly increased bladder capacity, by 144% (+/-127%) or 230 ml (+/-143 ml). In the conditional neuromodulation experiments, the gap between suppressed contractions fell reliably as bladder volume increased, and the time from start of stimulation to peak of intravesical pressure and 50% decline in intravesical pressure rise was 2.8 s (+/-0.9 s) and 7.6 s (+/-1.0s) respectively. The two methods of stimulation were compared in six patients; in four out of six conditional neuromodulation resulted in a higher mean bladder capacity than continuous, but the difference was not significant.

CONCLUSIONS

Both conditional and continuous stimulation significantly increase bladder capacity. The conditional mode is probably at least as effective as the continuous, suggesting that it could be used in an implanted device for bladder suppression.

Establishing predictive indicators for the status of loaded soft tissues

Two complementary techniques were employed to assess the soft tissue response to applied pressure. The noninvasive methods involve the simultaneous measurement of the local tensions of oxygen and carbon dioxide (tcPo 2 and tcPco 2) and the collection and subsequent analysis of sweat collected from the sacrum, a common site for the development of pressure sores. All tests were performed on able-bodied subjects. Results have indicated that oxygen levels (tcPo 2) were lowered in soft tissues subjected to applied pressures of between 40 (5.3 kPa) and 120 mmHg (16.0 kPa). At the higher pressures, this decrease was generally associated with an increase in carbon dioxide levels (tcPco 2) well above the normal basal levels of 45 mmHg (6 kPa). There were also considerable increases, in some cases up to twofold, in the concentrations of both sweat lactate and urea at the loaded site compared with the unloaded control. By comparing selected parameters, a threshold value for loaded tcPo 2 was identified, representing a reduction of ∼60% from unloaded values. Above this threshold, there was a significant relationship between this parameter and the loaded/unloaded concentration ratios for both sweat metabolites. These parameters may prove useful in identifying those subjects whose soft tissue may be compromised during periods of pressure ischemia.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

The fissura antitragohelicina: an anatomic aid to the correction of prominent ears

One of the important features of correction of prominent ears involves the creation of an antihelical fold in the ear cartilage. The precise and symmetrical location of this fold is crucial for the aesthetic result. This study investigated the use of the fissura antitragohelicina, a constant anatomic landmark, as a guide to the correct line for the new antihelix. In the first part of the study, 16 cadaveric ears were dissected. The fissura antitragohelicina was present in each specimen, and measurements of the distance between the fissura antitragohelicina and the helix and the antihelix were recorded. Based on this study, a clinical series of 20 consecutive prominent ear corrections were performed using the fissura antitragohelicina as a guide for the creation of a new, symmetrical antihelical fold. The aesthetic results were satisfactory by subjective assessment in every one of this group of patients. This study showed that the fissura antitragohelicina was a constant, reliable, and simple guide to the creation of the antihelical fold in patients with prominent ears.

Malignant schwannoma in a burn scar

The malignant potential of a burn scar is well recognized. Epidermal malignancies predominate and sarcomas are a rare finding. The first case of a malignant schwannoma developing in a burn scar is reported, and the management discussed.

Fungal growth within a silicone tissue expander: case report

Fungal contamination of tissue expanders has not previously been reported. There are, however, reports of fungi in association with inflatable breast prostheses. Colonisation of a tissue expander with Aspergillus niger resulting in mechanical obstruction of the device is described. The possible modes of inoculation and survival of the organism within the expander envelope were studied including an investigation of the permeability to gases of the silicone expander envelope. Recommendations are made about prevention of this complication.

Double V-Y advancement flaps in the reconstruction of skin defects of the anterior lower limb

A double V-Y advancement flap based upon a vertical subcutaneous pedicle was assessed for reconstruction of moderate sized defects of the anterior lower leg. The technique is described and the results of a retrospective analysis of thirteen cases are given. The procedure has proven to be a reliable alternative means of providing skin cover in this area.

Neonatal cleft lip repair in Ayrshire; a contribution to the debate

Neonatal cleft lip repair has been the normal practice in Ayrshire, Scotland, for the last 10 years. The surgical results are briefly presented. Anaesthetic and paediatric considerations are discussed. Assuming careful preoperative assessment is made, the procedure carries minimal morbidity, can give good results and is believed to offer distinct advantages to the parents and child.

Effects of incandescent radiation on photosynthesis, growth rate and yield of 'Waldmann's Green' leaf lettuce

Effects of different ratios incandescent (ln) to fluorescent (Fl) radiation were tested on growth of 'Waldmann's Green' leaf lettuce (Lactuca sativa L.) in a controlled environment. After 4 days of treatment, dry weight, leaf area, relative growth rate (RGR), net assimilation rate (NAR), leaf area ratio (LAR) and photosynthetic rate (Pn) were greater for plants grown at 84 rather than 16% of total irradiance (82 W m-2) from ln lamps. Although leaf dry weight and area were 12-17% greater at 84% ln after the first 8 days of treatment, there were no differences in RGR or Pn between treatments during the last 4 days. If 84% ln was compared with 50% ln, all cumulative growth parameters, RGR, NAR and Pn were greater for 84% ln during the first 4 days of treatment. However, during the second 4 days, RGR was greater for the 50% ln treatment, resulting in no net difference in leaf dry weight or area between treatments. Shifting from 84 to 50% ln radiation between the first and second 4 days of treatment increased plant dry weight, leaf area, RGR and NAR relative to those under 84% ln for 8 days continuously.

Effects of CO2 and photosynthetic photon flux on yield, gas exchange and growth rate of Lactuca sativa L. 'Waldmann's Green.'

Enrichment of CO2 to 46 mmol m-3 (1000 mm3 dm-3) at a moderate photosynthetic photon flux (PPF) of 450 micromoles m-2 s-1 stimulated fresh and dry weight gain of lettuce leaves 39% to 75% relative to plants at 16 mmol m-3 CO2 (350 mm3 dm-3). Relative growth rate (RGR) was stimulated only during the first several days of exponential growth. Elevating CO2 above 46 mmol m-3 at moderate PPF had no further benefit. However, high PPF of 880-900 micromoles m-2 s-1 gave further, substantial increases in growth, RGR, net assimilation rate (NAR) and photosynthetic rate (Pn), but a decrease in leaf area ratio (LAR), at 46 or 69 mmol m-3 (1000 or 1500 mm3 dm-3) CO2, the differences being greater at the higher CO2 level. Enrichment of CO2 to a supraoptimal level of 92 mmol m-3 (2000 mm3 dm-3) at high PPF increased leaf area and LAR, decreased specific leaf weight, NAR and Pn and had no effect on leaf, stem and root dry weight or RGR relative to plants grown at 69 mmol m-3 CO2 after 8 d of treatment. The results of the study indicate that leaf lettuce growth is most responsive to a combination of high PPF and CO2 enrichment to 69 mmol m-3 for several days at the onset of exponential growth, after which optimizing resources might be conserved.

Minitron II system for precise control of the plant growth environment

A transparent, cylindrical chamber system was developed to allow measurement of gas-exchange by small crop canopies in the undisturbed plant growth environment. The system is an elaboration of the Minitron system developed previously to compare growth of small plants in different environments within the same general growth area. The Minitron II system described herein accommodates hydroponic culture and separate control of atmospheric composition in individual chambers. Root and shoot environments are compartmented separately to accommodate atmospheres of different flow rate and/or gaseous composition. A series of 0-rings and tension-adjustable springs allow carbon dioxide in the flowing atmosphere to be analyzed without cross-contamination between chamber compartments or from external gas sources. Carbon dioxide has been maintained at set point +/- 9 g m-3 over a range of CO2 concentrations from 382 to 2725 g m-3 and with an atmosphere turnover rate of 136.7 cm3 s-1 by computer-assisted mass flow controllers. Each chamber has dimensions large enough (61 cm internal diameter, 0.151 m3 internal volume) to allow adequate replication of individual plants for statistical purposes (e.g., up to 36 equally-spaced plant holders). No significant variation in growth or photosynthetic rate of leaf lettuce occurred between chambers for a given set of environmental conditions. Gas-exchange rates in different chambers changed to a similar extent as CO2 concentration in the flowing atmosphere or chamber temperature were varied by the same amount. When coupled with appropriate control systems, Minitron II chambers can provide separate controlled environments for multiple small plants with adequate precision and at relatively low cost.

Growth and yield characteristics of 'Waldmann's Green' leaf lettuce under different photon fluxes from metal halide or incandescent + fluorescent radiation

'Waldmann's Green' leaf lettuce (Lactuca sativa L.) was grown either under 84% irradiance from incandescent (In) + 16% from fluorescence (Fl) lamps, or 100% from metal halide (MH) lamps, both at 392 micromoles s-1 m-2 of photosynthetically active radiation (400-700 nm) from 11 to 19 days after seeding. No differences in leaf dry weight, leaf area, relative growth rate (RGR) or photosynthesis (Pn) occurred after 8 days of exposure to these radiation treatments for 20 h day-1. However, a 23% reduction in root dry weight, a 123% increase in stem length and a 61% increase in stem dry weight were found with In + Fl relative to MH radiation. A photosynthetic photon flux (PPF) of 920 micromoles s-1 m-2 from the In + Fl source increased leaf dry weight by 13% and RGR by 21% relative to those at 460 micromoles s-1 m-2 from the same source. From 4 to 8 days of treatment, high PPF did not lower shoot dry gain, but did lower RGR. Photosynthesis and net assimilation rate were lower while leaf area ratio was higher at 460 than at 920 micromoles s-1 m-2 over the 8-day treatment period. When PPF from MH lamps was 400 micromoles s-1 m-2, leaf dry weight was 20% greater than if PPF was 805 micromoles s-1 m-2 after 4 days of treatment, but no differences were detected after 8 days. Relative growth rate increased by 11% during the first 4 days, but declined by 12% during the second 4 days under high- relative to low-PPF MH radiation. Lettuce productivity was stimulated by high PPF from either lamp type from Day 11 to Day 14, but not from Day 15 to Day 19 after seeding.

Stimulating productivity of hydroponic lettuce in controlled environments with triacontanol

Triacontanol (1-triacontanol) applied as a foliar spray at 10(-7) M to 4-day-old, hydroponically grown leaf lettuce (Lactuca sativa L.) seedlings in a controlled environment increased leaf fresh and dry weight 13% to 20% and root fresh and dry weight 13% to 24% 6 days after application, relative to plants sprayed with water. When applied at 8 as well as 4 days after seeding, triacontanol increased plant fresh and dry weight, leaf area, and mean relative growth rate 12% to 37%. There was no benefit of repeating application of triacontanol in terms of leaf dry weight gain.